A Disclosure of Ownership form is a document that Medicare and Medicaid require to understand who owns and controls your practice. This form is a necessary part of the enrollment process and helps ensure compliance with federal regulations.

Why Are We Asking You to Provide This Document?

If we are asking you to provide a Disclosure of Ownership form, it is likely because you are intending to enroll with Medicare or Medicaid. Medicare and Medicaid require this form to know who owns and controls your practice. It’s part of their rules for enrollment.

What Does the Document Include?

The form will include:

• Your Practice Information: Name, address, Tax ID, and NPI.

• Ownership Details: Names and addresses of all owners and their percentage of ownership.

• Control Information: Details about anyone who manages or controls the business, such as officers or directors.

• Criminal Background Info: Any criminal convictions related to healthcare, if applicable.

What If You Don’t Have the Document?

If you don’t have this document, you can download the template here. It’s a straightforward form that asks for the key details Medicare and Medicaid need for your enrollment.

Need Help?

If you’re unsure about what to include or how to fill out the form, our support team is here to assist you. We’ll guide you through the process to make sure everything is done correctly.